E-ISSN:2456-3110

Review Article

Sthula Madhumeha

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 11 NOVEMBER
Publisherwww.maharshicharaka.in

An Integrative approach in the management of Uncontrolled type 2 Diabetes Mellitus w.s.r. to Sthula Madhumeha: A Case Report

Jamale M1*, Gulhane JD2, Gaikwad M3
DOI:10.21760/jaims.9.11.34

1* Mohini Jamale, Post Graduate Scholar, Department of Kayachikitsa, Government Ayurved College and Hospital, Nagpur, Maharashtra, India.

2 JD Gulhane, Associate Professor, Department of Kayachikitsa, Government Ayurved College and Hospital, Nagpur, Maharashtra, India.

3 Mayur Gaikwad, Post Graduate Scholar, Department of Kayachikitsa, Government Ayurved College and Hospital, Nagpur, Maharashtra, India.

Introduction: Diabetes is a disease of worldwide importance and a major public healthcare concern owing to its associated morbidity. Clinically Type 2 DM resembles Madhumeha with prevalence in India was 9.6% in 2021.This case report describes an integrated approach for the treatment of uncontrolled diabetes mellitus.

Main clinical Findings: A 58-year-old male patient complained of polyurea, polyphagia, polydipsia, tingling, and severe burning in all 4 limbs, fatigue, and constipation. Investigations shows FBSL level of 247mg/dl, PPBSL 415mg/dl, and HbA1C 8.9%, BMI 28.6kg /m2.

Diagnosis: Sthula-Madhumeha (Type 2 Diabetes Mellitus).

Interventions: Treatment includes, Panchatiktapanchaprasutika Basti for consecutive 15 days (Kalbasti Krama), local therapy, oral medications and lifestyle modifications.

Outcome: Patient showed marked reduction in FBSL reduced to 82mg/dl PPBSL to 184mg/dl, and HbA1c to 6.8% after 3 months. Patient exhibited significant results in clinical signs and symptoms.

Conclusions: It can be concluded that Ayurvedic intervention can be a complimentary treatment in uncontrolled DM.

Keywords: Type 2 DM, Diabetes, Ayurveda, Panchtiktapanchaprasrutik Basti, Sthula-Madhumeha, Vasantkusumakar Ras.

Corresponding Author How to Cite this Article To Browse
Mohini Jamale, Post Graduate Scholar, Department of Kayachikitsa, Government Ayurved College and Hospital, Nagpur, Maharashtra, India.
Email: 		Jamale M, Gulhane JD, Gaikwad M, An Integrative approach in the management of Uncontrolled type 2 Diabetes Mellitus w.s.r. to Sthula Madhumeha: A Case Report. J Ayu Int Med Sci. 2024;9(11):248-254.
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Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-10-11 2024-10-20 2024-10-30 2024-11-09 2024-11-19
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© 2024by Jamale M, Gulhane JD, Gaikwad Mand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Download PDFBack To ArticleIntroductionCase ReportDiscussionResultConclusionReferences
Mohini J et al. Management of Uncontrolled type 2 Diabetes Mellitus

Introduction

Diabetes is a chronic, metabolic condition characterized by elevated levels of blood glucose (or sugar), on long term which leads to serious damage to the heart, blood vessels, eyes, kidneys and nerves. Hyperglycaemia (raised blood glucose or sugar), is a common effect of uncontrolled diabetes and causes catastrophic damage to many of the body's systems, especially the nerves and blood vessels. In 2019, diabetes was the direct cause of 1.5 million deaths and 48% of all deaths due to diabetes occurred before the age of 70 years. Another 460000 kidney disease deaths were caused by diabetes, and raised blood glucose causes around 20% of cardiovascular deaths.[1] It is a major healthcare concern worldwide due to associated morbidity its prevalence in India is 9.6% in 2021. The global increase in obesity rates has paralleled the rise in T2DM prevalence.[2] In individuals with obesity, excess fatty tissue, particularly visceral fat, releases a variety of bioactive substances, such as free fatty acids, inflammatory cytokines (e.g., TNF-alpha, IL-6), and adipokines (e.g., leptin, resistin). These substances interfere with the insulin signalling pathways, leading to decreased glucose uptake by cells and elevated blood glucose levels.[3] So, it is necessary to treat obesity and diabetes for better outcomes.

Modern antidiabetic medications provide notable results for the treatment of type 2 diabetes, particularly in blood sugar management. However, these drugs have limitations, including side effects, high cost, limited efficacy in certain populations, and potential long-term complications. Additionally, these medications do not reverse the course of the disease; rather, many patients require multiple drugs to maintain glycemic control. Furthermore, a few regularly prescribed medications can cause weight gain, which is detrimental to the management of type 2 diabetes.[4] It draws attention to the necessity of individualized treatment plans and the development of new therapies with improved safety profiles and efficacy. Diabetes and obesity are related conditions that arise from metabolic abnormalities. So, reversing the metabolic disruption is the first step in managing both conditions. Therefore, the goal of this treatment is to break the pathogenesis of Disease, which lowers the risk of developing complications.

Case Report

A 58-year-old man came to our institute's OPD complaining of weight gain, polyuria, polyphagia, tingling and burning in his upper and lower limbs with generalized weakness, constipation for a year, and a recently cataract was diagnosed. He was advised to undergo surgical treatment for the cataract, but his uncontrolled diabetes delayed his surgery. So, patient was also worried about his pending surgery.

Personal history

The patient was K/C/O type 2 DM for five years taking metformin 500 mg BID along with an anti-diabetic diet, and also K/C/O hypertension for five years, he was taking Telma 40 mg 1OD for it.No noteworthy family history had been provided by the patient. The patient had a habit of drinking tea- 5-6 cups/day, sleeping in the daytime for 2hrs daily patient also had a history of tobacco and bettle nut chewing for 15 years and had stopped since 2 years.

Clinical Findings

Physical Examination

On examination patient GC was fair/ Afebrile with Weight: 80 kg; height: 168 cm, and BMI: 28.36kg/m2; Built was Obese. Blood pressure = 130/90 mm Hg; Pulse rate = 74/minute; pallor, icterus, cyanosis, clubbing, and edema were absent; On Systemic Examination cardiovascular system (CVS): S1 S2 normal; respiratory system (RS): clear no adventitios sound; central nervous system (CNS): consciousness, orientation, memory, and speech are normal; Reflexes in both upper and lower limbs were normal and muscle power was elicited as 5/5 in all limb.

Ashtavidha Parikshan

Nadi (~pulse) - Kaphapittaj

Mal - frequent - Vibandh (~constipation)

Mutra (~urine) - normal

Jivha (~tongue) - coated

Shabd (~speech) - clear

Sparsh (~temperature) - normal

Drik (~vision)- blurring of vision (K/C/O- B/L eye cataract)


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Mohini J et al. Management of Uncontrolled type 2 Diabetes Mellitus

Aakriti (~body built) - Sthula (~obese) BMI 28.36 kg/m2.

Timeline

The timeline of treatment is explained in Table No. 1

Table 1: Timeline

DateTreatment planDoseAushadhi Sevan Kal & AnupanaKarma
03/05/23(Guduchi, Triphala, Musta) Kwath40ml BDApaneSrotoshodhan, Pachan
Haritaki Churna5gmNishakale with lukewarm waterAnulomana(a purging medicine; stimulates evacuation of the bowels)
11/05/23Kalkrama Basti15 daysnormalizes Vata, Kapha, Meda, Kleda. potentiates the Agni and helps in Ama -Pachana.
AANANAN
ANANANAA		Panchatikta Pramehaghna Basti
(for details refer Table No. 5)		500mlMorning before meal
Anuvasan -Triphaladi Tail 120mlMorning after meal
11/05/23 -
02/06/23		Nisha- Amalaki Churna 5gm
21days		Apane- Vyane
with lukewarm water		Reduces Kleda, Kapha Shaman
11/05/23 -
10/06/23		Gokshuradi Guggulu500mg
30 days		Vyanudane with lukewarm waterBasti Shodhaka, Kledaghna, Medoghna, Mehaghna, Tridoshaghna, Shothaghna, and Lekhana properties
27/05/23 -
10/06/23		Udvartan with Triphala, musta churna30minutes
14 days		MorningRukshana, Lekhana, Kledahara
28/05/23 -
18/05/23		Vasantkusumakar Ras250mg
21 days		Rasayane with Ghrita & Madhu in unequal quantityReduces Dhatushaithilya, Dhatukshaya, Dhatuksharan and useful in Ojodushtiavastha of diabetics. Dhatuposhan - Balya, Rasayana

Diagnostic Assessment

According to signs and symptoms and laboratory investigations, patient was diagnosed as obese type 2 DM (Sthulmadhumeha). On laboratory investigation, he had FBSL-247mg/dl and PPBSL-415 mg/dl with HbA1c - 8.9 on admission.

He had normal C- Peptide level of 4.04 ng/ml. Cholesterol was 162 mg/dl, triglycerides were 237.7 mg/dl, urine sugar Nil. CBC, kidney and liver function test within normal limit. Details are summarized in Table No.6.

Based on height, weight, BMI, Abdominal circumference, waist circumference, waist-hip ratio summarised in Table No. 2 patient was diagnosed as Obese. Subjective parameter score of Prameha Symptoms was 12 out of 18 mentioned in Table no. 3.

Table 2: Anthropometric parameters

Anthropometric parameters/Date03/05/2327/05/2321/06/23
Weight (kg)807471.45
Height (cm)168168168
BMI (kg/m2)28.3626.225.3
Waist circumference (cm)11010399
Hip circumference (cm)108105100
Waist hip ratio1.010.90.99

Table 3: Subjective Parameters Score (Prameha Rupa assessment parameter with grading)

Subjective Parameters Gradation ScoreBefore TreatmentAfter Treatment
Prameha Rupa assessment parameter with grading11/184/18

Therapeutic Intervention

Mentioned in Timeline and Investigation Table.

Follow-up and Outcomes

Following 45 days of treatment, it was noted that the weight, BMI, waist-hip ratio, abdominal circumference, PPBSL, and FBSLwere reduced.

In addition, after three months, HbA1c level also decreased. there was also notable reduction in signs andsymptoms of Diabetes. Patient also undergo cataract surgery after treatment which was on hold due to uncontrolled diabetes before treatment.


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Table 4: Prameha Rupa assessment parameter with grading

SNSymptoms / Gradation0123
1.Mutramadhurya (Glycosuria)Absence of glucose in urineTraces of Glucose in urine+ Glucose in urine++ Glucose in urine
2.Prabhuta Mutrata (Polyuria) - Frequency of urination3 - 5 times per day, rarely at night6 - 8 times per day, 1 - 2 times per night9 - 11 times per day 3 – 4 times per night> 11 times per day > 4 times per night
3.Pipasa-Adhikya (Increased
Thirst)		No thirstDrinking water satisfy the thirst, dryness of mouth, throatFrequent feel to drink waterSevere (Feeling of severe thirst, waking up night to drink)
4.Kshudha-Adhikya (Increased Appetite)No appetite/very poorOccasional hunger/ eating only few
mouthful/one third
plate		Two to three meals per day, comfortable,
neither hungry nor full		Feeling hungry all the time with several hunger
symptoms
5.Klama (mental fatigue)No fatigue and mental effort not reducedFatigued quickly but still able to make some mental effortFatigue on certain physical functionsFatigue at rest, interfering work family or social life
6.Purishabaddhata (Constipation)Stool passes as per normal schedulePasses stool with strain, sometimestakes purgativePasses stool after more than 24 hours, frequently takes purgativePasses stool after gap of one day, normal purgatives does not work

Discussion

The progression of diabetes, especially poor glycaemic control, leads to numerous potentially life-threatening complications and has a negative impact on both health systems and individual well-being. Also Charak included Madhumeha in Astaumahagad (~Eight major Diseases). So, it is must to control BSL and manifestations of Diabetes in order to avoid life threatening complications. Though patient was taking allopathic medications regularly since years still had poor glycaemic control and suffering with its manifestation.

So, he turned towards ayurveda to get through this condition as alternative treatment. After examination patient was diagnosis according to ayurveda concepts as Sthula-Madhumeha. Then treatment was planned after understanding Nidanpanchak of Disease. According to Ayurved, In Madhumeha, due to the disturbance in Agni, vitiation of Kapha, Pitta, Meda, and Mansa Dhatu and their buildup at Basti obstructs Natural passage of Vayu and leads to disease.[5]

Probable mode of action of formulations

The line of treatment for this condition requires Deepana, Pachana, Lekhana, Vata-Kaphahara, and Medohara intervention. Therefore, Nityavirechan and Triphaladi Kwath[6] were given for Srotoshodhan, Aamapachan & Anuloman. Haritaki is used for mild purgation therapy in DM-II as it decreases hepatic glucose utilization resulting in hypoglycemic action. It may also increase stimulation of the enteric nervous system to accelerate intestinal motility.[7]

Then after Deepana Pachana, Basti was administered with Panchatikta Kwatha, Ghrita, Sarshapa Kalka and Saindhava in quantity mentioned in Table no.5. this Basti was mentioned in Charak Siddhi Sthana,[8] specifically for Prameha as Panchatiktapanchaprasrutika Pramehaghna Basti. Basti have a potent role in the Vata-Anulomana and regulation of Dhatusamya as it drained impurities (Mala) from the micro and macro channels of Dhatu. Result in breakdown of pathogenesis of Madhumeha as Kleda expel out in the form of Basti Pratygaman.

Following Basti, Gokshuradi Guggulu was advised. It carries Kledaghna, Medoghna, Tridoshghna, Lekhana, Shothaghna properties. also help to prevent complications like diabetic nephropathy. Scraping, or the Lekhana property, can be used to remove any blockage in both macro-and microvessels. As such, it rectifies the Srotorodha in Mootravaha and Medovahasrotas.[9] Along with it, Nisha-Amalaki Churna reduces Kleda and rectifies Dhatvagnimandya. And directly influence both Dosha and Dushyavishesha, that is, Bahudrava Shleshma & Kleda, thus counteracting Samprapti.[10] It also acts as Naimittak Rasayana in Madhumeha, as it has antidiabetic,hypoglycemic, and antiatherosclerotic properties due to the chemical composition of curcumin and vitamin C, with anti-inflammatory and antioxidant properties it might have helped control the disease.[11]


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Use of Udwartana with Triphala Churna, that is, rubbing Triphala powder on the body in the direction opposite to hair root. It results in Twakprasadana (skin nourishment), and Kapha-Meda Vilayana (liquification of Kapha and Medas). This can be useful in reducing body fat and weight loss.[12]

Table 5: Showing contents and Procedure of PPP Basti

SNIngredientsQuantity
1.Saindhav lavana 5 gm
2.Go ghrita 100 ml
3.Sarshapa kalka 50 gm
4.Rasna, Nimba, Patol, Saptaparn, Chirayata Kwath 400 ml
Basti Procedure
Type: Kalakrama - AANANANANANANAA
A - Anuvasana Basti, N - Niruha Basti
Poorvakarma: Sarvang Snehana - using Tilatail for 20 min, Nadiswedansa - with Dashamool Kwath upto Swedaagamana (approx. 20 minutes)
Pradhanakarma:
Patient was asked to lie down in (Vamaparshwa) left lateral position with left leg straight and right leg flexed on Basti table.
Rubber catheter and Anal ridge were lubricated using Sneha then ¼th length of rubber catheter (connected to oil filled Syringe) was inserted into anal canal. Small amount of Basti Dravya was kept in syringe and catheter was removed.
Anuvasana Basti given Ardrapani (~ Just after having light meal) With Koshna (~Lukewarm) Triphaladi Taila 120ml and
For Niruha Basti contents were mixed in sequence Saindhava, Goghrita, Sarshapakalka, then Koshna Kwatha of Panchtikta drugs added titration done and Basti was given empty stomach by following procedure as mentioned above for Anuvasan Basti.
Paschatakarma:
The patient was instructed to lie down on supine position for 10-15 mins after Basti and to defecate on developing urge.        
Basti Deya Kal and Pratyagamana Kala (Retention Time of enema) of every Basti was noted.

After Kleda removal Vasantkusumakar Ras,[13] a powerful antidiabetic medication, was used as a Rasayan. It contains Swarna, Naga, Vanga, and other body tissue-promoting or immunomodulatory agents that corrects Dhatu Kshaya in Madhumeha in the form of tissue repair, antioxidant activity, pancreatic stimulation, rejuvenation, anti-atherosclerosis, and hypoglycemic effects. Some animal studies have highlighted its potential to prevent diabetic complications such as hepatomegaly, nephropathy, and retinopathy.[14]

Along with this treatment, patient was advised to do daily 30 minutes walking exercise along with diet that includes exclusion of foods that are high in salt, sugar and fat. It has a protective effect and can prevent the development of diabetic complications by maintaining good glycemic control. Further research and studies on the application of Ayurveda in the treatment of type 2 diabetes are required to prove this.

Result

After treatment patients BSL almost returned to normal also HbA1c was reduced to 6.8. Significant reduction also achieved in terms of clinical manifestations of Madhumeha leads to improvement in QOL of patient. Reduction in Weight, BMI, waist circumference, hip circumference, waist-hip ratio was also observed. Result summarised in table No. 2 & 6.

Table 6: Investigation

Investigation/date03/05/2308/05/23 On admission19/05/2312/06/2321/06/2315/08/23
BSL- fasting (mg/dl)2472301559483
Post meal (mg/dl)415371269282162
HbA1c (%)8.96.4

Investigation/date08/05/23 On admission21/06/23
Cholesterol (mg/dl)162.66124
triglyceride (mg/dl)237.7195.5
ldl (mg/dl)96.696.6
hdl (mg/dl)58.6433.6
Haemoglobin (gm/dl)1111.4
TLC (/cumm)86008000
DLC
Lymphocytes (%)5749
Eosinophills (%)3634
Monocytes (%)75
Platelets(lakh/cumm)1.011.34
Blood urea(mg/dl)24.428.2
Sr. Creatinine(mg/dl)1.031.3
uric acid(mg/dl)7.17.1
Urine routine micro
A/bNILNIL
SugarNILNIL
C-peptide (ng/ml)4.04-

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Conclusion

This integrated approach, using oral Ayurvedic drugs, Panchakarma procedures, and diet, can be effective in treating patients with type2 DM. It can be a major and efficient integrative and alternative management option for Diabetes Mellites and for the prevention of its complications and also in the treatment of metabolic disorders by correction of metabolic derangement.

Declaration of patient consent

Authors certify that they have obtained a patient consent form, where the patient has given his consent for reporting the case along with other clinical information in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

References

1. World Health Organisation. Diabetes Overview [Internet]. 2023 [cited 2024 Feb 5]. Available from: https://www.who.int/news-room/fact-sheets/detail/diabetes

2. Kumar A, Gangwar R, Zargar AZ, Kumar R, Sharma A. Prevalence of diabetes in India: a review of IDF Diabetes Atlas 10th Edition. Curr Diabetes Rev. 2024;20(1):105-14. doi: 10.2174/1573399819666230413094200.

3. Li M, Chi X, Wang Y, et al. Trends in insulin resistance: insights into mechanisms and therapeutic strategy. Signal Transduct Target Ther. 2022;7(216). doi: 10.1038/s41392-022-01073-0.

4. Hollander P. Anti-diabetes and anti-obesity medications: effects on weight in people with diabetes. Diabetes Spectr. 2007;20(3):159-65. doi: 10.2337/diaspect.20.3.159.

5. Sharma AR. Sushrut Samhita. Varanasi: Chaukhambha Pratishthan; 2017. Nidansthana, Adhyay 6/4.

6. Kale VS. Charak Samhita.Chaukhambha Sanskrit Pratishthan; 2013. Sutrasthan, Adhyay 21/21-23. p. 117.

7. Jirankalgikar YM, Ashok BK, Dwivedi RR. A comparative evaluation of intestinal transit time of two dosage forms of Haritaki [Terminalia chebula Retz]. Ayu. 2012;33(3):447-9. doi: 10.4103/0974-8520.108866.

8. Geng J, Ni Q, Sun W, Li L, Feng X. The links between gut microbiota and obesity and obesity related diseases. Biomed Pharmacother. 2022;147:112678. doi: 10.1016/j.biopha.2022.112678.

9. Mangal A, et al. Evaluation of Gokshuradi Guggulu and Guduchi Churna in the management of Type II Diabetes Mellitus (Madhumeha). J Res Ayurvedic Sci. 2019. doi: 10.5005/jras-10064-0082.

10. Pandharkar G, Rasal P. Clinical efficacy of shodhanottara shamana chikitsa in type II diabetes mellitus – an exploratory study. Ayurlog. 2018;6(4):1-10.

11. Silva PASN, Arawwawala LDAM, Kumari MWSJ, Galappatthy P. Effect of Curcuma longa L. and curcumin on diabetes and its complications: a review. J Ayu Herb Med. 2021;7(2):109-18. doi: 10.31254/jahm.2021.7209.

12. Kumari S, SD L, B S, Khanal S. Efficacy of Integrated Ayurveda treatment protocol in Type 2 Diabetes Mellitus - A case report. J Ayurveda Integr Med. 2022;13(1):100512. doi: 10.1016/j.jaim.2021.08.005.

13. Gaidhani SN, et al. Antidiabetic activity of Vasant Kusumakar Ras in streptozotocin and high-fat diet induced Type 2 Diabetes Mellitus in Sprague Dawley rats. J Nat Remedies. 2023;23(2):521-36. doi: 10.18311/jnr/2023/32054.

14. Tamoli SM, et al. Vasant Kusmakar Ras, an ayurvedic herbo-mineral formulation prevents the development of diabetic retinopathy in rats. J Ayurveda Integr Med. 2020;11(3):270-6. doi: 10.1016/j.jaim.2020.02.002.

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